CHANGES IN MANDIBULAR

MOBILITY AFTER DIFFERENT

PROCEDURES OF
ORTHOGNATHIC SURGERY
Bernd Zimmer, Rainer Schwestka,
Dietmar Kubein-Meesenburg
 Introduction

• Among possible alterations in craniomandibular function resulting from

surgical-orthodontic procedures, changes in mandibular mobility have
been of major concern.
• Several authors have shown that hypomobility is a typical consequence of
various surgical procedures (Hogeman, 1951; Astrand et al., 1973; Storum
and Bell, 1984; Aragon et al., 1985). This seems to occur, to greater or
lesser extents, following mandibular and maxillary surgery (O'Ryan and
Epker, 1983a,b; Storum and Bell, 1984; Aragon et al., 1985).
• Modes of treatment, however, such as the method of intra-operative
fixation of bony segments, post-operative intermaxillary fixation, myotomy
of the suprahyoid musculature, etc., seem to influence the degree of
hypomobility (Schendel and Epker, 1980; Storum and Bell, 1984; Nitzan
and Dolwick, 1989).
• In the discussions on the reasons for hypomobility, surgery-induced
changes in condyleposition (Isaacson et al., 1978; Schendel and Epker,
1980; Kundert and Hadjianghelou, 1980; Sund et al., 1983) with all its
consequences play an important role.
• However, until now, concrete evidence as to whether intra-operative
methods for maintaining condyle-position may exert a favourable influence
on mandibular mobility has not been available.
• Moreover, only little knowledge exists concerning the time-dependency of
post-operative alterations with respect to mobility.
• It would be of interest to ascertain, which of the reported alterations are
transient and which are permanent.
• It was the intention of this study, to examine the time-dependency of
changes in mandibular mobility after different surgical procedures, which
had dispensed with intermaxillary fixation and in the case of mandibular
osteotomies, included a method for maintaining condyle position.
 Subjects and methods

• A prospective study including 63 adult Class II and Class III patients was
carried out. Fourteen of these, who were treated orthodontically only,
served as a control group (Group A, n=14, mean age 25 years, range 19-
38 years).
• Fortynine patients were treated with a fixed orthodontic appliance in
combination either with a LeFort I osteotomy (Group B, n= 14, mean age
25.4 years, range 18-34 years); a mandibular advancement by sagittal-
split osteotomy according to Obwegeser (1955) and Dal Pont (1959)
(Group C, n = 2l, mean age 28.9 years, range 18—45 years); or with a
simultaneous two-jaw surgical approach, including a mandibular setback
and a LeFort I-osteotomy (Group D, n — 14, mean age 25.4 years, range
19-33 years). Three of the group D patients were treated with a
mandibular setback only.
• Total length of treatment was 2 years 2 months (mean), with a range from
1 year 6 months to 3 years 2 months. That meant that, in all but five cases
(Group A: 3, Group C: 2), patients were out of active treatment at the end
of the investigation.
• Rigid fixation with mini-plates (HOWMEDICA) was employed in all cases,
for stabilization of the bony segments (Drommer and Luhr, 1981; Luhr,
1989). In groups C and D, condyleposition was controlled intra-operatively
by a method proposed by Luhr et al. (1986) and Kubein et al. (1987).
• In principle that method consisted of the temporary (intra-operative)
application of two mini-plates (one for- each side) that were attached to
the mandibular rami and the zygomatic bones before the sagittal split,
thus defining the original condylar position.
• After removal of these plates, the osteotomy was performed.
• Before the fixation of the mandibular corpus in its new position, the two
mini-plates had to be inserted again, using the original screw holes, and
thus guaranteeing the original condyle-fossa relationship.
• Now, displacement of the mandibular corpus and its refixation could be
done while the miniplates prevented dislocation of the condylar-bearing
segments due to muscle-pull or during fixation. Post-operatively,
intermaxillary fixation was not employed in any group. Instead, guiding
splint in combination with Class II or Class III elastics was used. Splint
and elastics could be removed for eating and cleaning, from about the
fifth post-surgical day, by the patient.
• In the surgery-groups, maximum opening, protrusion and lateral
excursions were measured 2 days pre-operatively (TO) and 3, 8, 14.5,
and 25.5 months post-operatively (T1-T4). In the control-group
measurements were taken at TO and T4, only.
• All measurements were begun in centric occlusion. After repeated trials,
measurements were carried out at the incisal points with a DENTAURUM
gauge (No.042-751) and afterwards by use of an electronic-axiographic
device (SAS-SYSTEM, Munique).
• This system comprised an upper and a lower face-bow, the latter attached
to the labial surfaces of the lower teeth by means of an individually fitted
tray and glass-ionomer cement.
• Close to the condyles, the lower face-bow carried an electronic writing
instrument which transferred mandibular movements to a resistance foil
that was attached to the upper face-bow. After the individual hinge-axis
had been determined, the system permitted a ten-fold magnification of
registrations of hinge-axis movements on an XY-plotter, and thus, could
be used as an approximation of the movement of the lateral pole of the
condyle (Meyer, 1982).
• Registrations of repeated movements and calculation of the lengths of
tracings were carried out as was described previously (Zimmer et al.,
1991).
• Examined movements and abbreviations used:
1. PI-Open.inc.: opening measured incisally;
2. P2-Pro.inc: protrusion measured incisally;
3. P3-Lat.r.inc: right lateral excursion measured incisally;
4. P4-Lat.l.inc.:. left lateral excursion measured incisally;
5. P5-Open.r.ax: opening right joints measured axiographically;
6. P6-Open.l.ax: opening left joints measured axiographically;
7. P7-Pro.r.ax: protrusion right joints measured axiographically;
8. P8-Pro.l.ax: protrusion left joints measured axiographically;
9. P9-Lat.r.ax: laterotrusion right joints measured axiographically;
10.PO-Lat.l.ax: laterotrusion left joints measured axiographically.
• Statistical values and significances of differences in measurements
presented in Tables 1-4 do not show results for the parameters P4,
P6, P8, and P9.
• If no special information is given, the results of these parameters
correspond to those of the opposite side.
• The Wilcoxon-test was used to detect differences between different
points of time within each group.
 Results
1. Group A—orthodontic treatment Following orthodontic treatment (Group
A), only slight alterations in mandibular mobility could be detected in the
control period of 25.5 months (Table 1).
2. Such alterations were found in opening, pro- and laterotrusion, both when
measured at the incisal point (P1-P4) and at the hinge-axis points (P5-
P0). None of these alterations was significant. Differences between
patients who were already finished with active orthodontic treatment (11
patients) and those who were still in treatment (three patients) were not
obvious. Accordingly, the conclusion was drawn that orthodontic treatment
under the circumstances prevailing in this study did not influence
mandibular mobility. Typical 'alterations' of axiographic protrusive tracings
in Group A are presented in Fig. 1 (upper left sequence).
• Group B—LeFort I osteotomy After a LeFort I osteotomy, opening
mobility decreased between the pre-operative (TO) and 3-months post-
operative (Tl) control (Table 2). The median, for instance, dropped by 9
per cent from 46 to 42 mm, and the maximum value by 12.5 per cent
from 56 to 49 mm.
• These alterations were slight, but statistically significant (P<0.01).
Gradual increases from Tl to T4 compensated for the initial decrease, so
that 25.5 months post-operatively, opening mobility was statistically
unchanged compared to the pre-operative values.
• In protrusion and lateral excursions (right and left) incisal measurements
showed no significant alterations between any points of time (Table 2).
• Correspondingly, lengths of axiographic tracings during maximum
opening, protrusion, and laterotrusion (P5-P0) did not show a significant
alteration between any points in time.
• In spite of the fact that opening mobility reduced incisally, but not
axiographically between TO and Tl, axiographic measurements did not
reveal controversial results.
• It is concluded that mandibular mobility remained unaltered by LeFort I
osteotomies. Typical findings of axiographic protrusive tracings are
presented in Fig. 1 (upper right sequence).
• 3. Group C—mandibular advancement Incisal measurements revealed
that after sagittal-split osteotomies with subsequent mandibular
advancements (Group C), a remarkable decrease in mandibular mobility
occurred from the pre-operative (TO) to the 3-month postoperative
measurement (Tl). This reduction could be seen in all movements. Median
values decreased by 31 per cent in opening, by 60 per cent in protrusion,
and by 36 per cent in right lateral excursion (Table 3). Reductions in all
movements were highly significant (P< 0.001) at this early time point
(Table 4).
• Between 3 (Tl) and 8 months (T2) postoperatively, opening (P< 0.001) and
protrusion (P<0.05), but not laterotrusion, increased significantly. 14.5
months (T3) post-operatively, mobility had increased again significantly
(P<0.05) in opening compared to the 8-month (T2) values. No further
increases took place after 14.5 months (T3). Thus, values for lateroand
protrusion remained stable after only 3 and 8 months, respectively.
• It is important to note that in all movements, increases after Tl could not
completely compensate for the initial reductions, so that 25.5 months post-
operatively, mobility values remained significantly reduced compared to
preoperative ones. This was more obvious in pro(33 per cent reduction)
and laterotrusion (27 per cent reduction) than in opening (9 per cent
reduction).
• As was found with incisal measurements, significant reductions in lengths
of axiographic tracings from TO to Tl were detected in all movements.
• Between Tl and T2, however, lengths of axiographical tracings increased
only in protrusion on the left side, whereas values for opening (right and
left), laterotrusion (right and left) and protrusion (right) remained almost
constant. After the 8-month control (T2), no significant increases could be
detected at all. Since post-operative increases were missing (opening and
laterotrusion) or insufficient (protrusion), mobility of all movements
remained significantly reduced, compared to the pre-operative values.
• We concluded that sagittal-split osteotomies with subsequent mandibular
advancements result in a permanent reduction in mandibular mobility. The
survey revealed that mobility reduction is induced by surgical intervention
which is followed by a movement-dependent short, but incomplete period
of recovery.
• Alterations in statistical values in the course of the 25.5-month control
period are presented for protrusive tracings of the right joints in Fig. 2.
• Typical alterations of axiographic protrusive tracings are presented in Fig.
1 (lower left sequence). The comparison of results of incisal and
axiographical measurements showed corresponding initial and long-term
reductions. However, differences were present with respect to the duration
and significance of post-operative increases mainly in opening. This fact
permitted development of a theory as to the nature of restriction of
condylar movements (see discussion).
• 4. Group D—two-jaw surgery Incisal measurements revealed a reduction
in opening mobility from TO to Tl (/><0.05) in the two-jaw
surgery/mandibular advancement group (Group D). The median was
reduced by 25 per cent from 50.5 to 38 mm in opening, while values even
showed a slight increase in protrusion (from 5.5 to 6 mm) and in right
lateral excursion (from 7.5 to 8 mm).
• Between the 3rd (Tl) and 8th (T2) month post-operatively, opening mobility
increased significantly (.P<0.05) and the median increased up to 49 mm.
• From T2 to T3, protrusive mobility increased significantly (.P<0.05). 25.5
months (T4) post-operatively, no significant alterations could be found
compared to preoperative values (TO).
• In accordance with incisal measurements, significant reductions in
opening mobility were found axiographically on both sides from TO to Tl. A
later increase could be found on the right side between T3 and T4
(/»<0.05).
• Nevertheless, values at T4 were not significantly different from pre-
operative values. While no alterations in lengths of protrusive tracings
could be detected between any points of time, significant increases in
laterotrusive tracings were found from Tl to T2, T2 to T3 (right), and from
T2 to T3 (left). However, as in opening and protrusion, lengths of-tracings
at T4 were not significantly different from TO values.
• Comparison of the two types of determination of mobility again
demonstrated good agreement with respect to the immediate post-
operative developments (T0-T1) and longterm stability (T0-T4) of values.
• In contrast, discrepancies were detected in recovery or even gain of
mobility in some intervals. However, they were not long-term effects and
their significance should not be overemphasized.
• From the present data the conclusion can be drawn that two-jaw surgery,
including a LeFort I and a sagittal split-osteotomy with mandibular setback
or a sagittal split-osteotomy with mandibular setback only, do not result in
permanent reductions in mandibular mobility. Temporary reductions were
detected in opening only and were confined to a period of, at the most, 6
months. Figure 3 shows statistical values in this group for protrusive
tracings of the right joints at points TO to T4. Alterations of typical
axiographic protrusive tracings are presented in Fig. 1 (lower right
sequence).
Table 1 (Group A) Values (maximum, median, 75-25 per
cent: fifth percentile, minimum, mean, SD) in millimeters
for parameter. PI: opening measured incisally; P2:
protrusion measured incisally; P3: right lateral excursion
measured incisally; P5: opening right joints measured
axiographically; P7: protrusion right joints measured
axiographically; and PO laterotrusion left joints measured
axiographically before and after an orthodontic treatment.
TO, T4 see Fig. 1. No significant differences were found in
this group.
Table 2 (Group B) Values (maximum, median, 75-25 per cent: fifth percentile,
minimum, mean, SD) in millimeters for parameter P1-P3, P5, P7 and PO
(explanations see Table 1) before and after a LeFort I osteotomy. TO: 2 days
pre-op.; Tl: 3 months post-op.; T2: 8 months post-op.; T3: 14.5 months post-
op.; T4: 25.5 months post-op. Only PI between TO and Tl showed a
significant difference (P<0.01).
Table 3 (Group C) Values (maximum, median, 75-25 per
cent: fifth percentile, minimum, mean, SD) in millimeters
for parameter P1-P3, P5, P7 and PO (for explanations see
Table 1) before and after a mandibular advancement. T0-
T4 see Table 2. Significances of differences see Table 5.
Table 5 (Group D) Values (maximum, median, 75-25 per cent: fifth percentile, minimum, mean, SD) in millimeters for
parameter P1-P3, P5, P7 and PO (explanations see Table 1) before and after a two-jaw surgery/ mandibular setback.
T0-T4 see Table 2. Significances of differences were present for PI from TO to Tl (/><0.05) and Tl to T2 (/><0.05), for
P2 from T2 to T3 (/><0.05), for P5 from TO to Tl (/><0.05) and T3 to T4 (P<0.05), and for PO from T2 to T3 (P<0.01),
respectively.
 Discussion

• In accordance with earlier investigations, our findings demonstrated that

reductions in mobility are highly dependent upon the kind of surgical
procedure employed.
• As already reported by Storum and Bell (1984) and Aragon et al. (1985) it
was found that after sagittal-split surgery and consecutive advancement of
the mandible, reductions in mandibular mobility were most pronounced.
• Because in this group, significant increases in mobility beyond 14.5
months post-surgery could not be detected and in most measurements
not even tendencies for slight later increases were present, these
reductions must be accepted as permanent.
• In contrast to previous studies, long-term or even permanent reductions
were not found after LeFort I osteotomies (O'Ryan and Epker, 1983a;
Aragon et al., 1985) or mandibular setbacks (Astrand et al., 1973; Edlund
et al., 1978; Aragon et al., 1985).
• Our results can be interpreted as a favourable consequence of the use of
rigid fixation that allowed for the intraoperative insertion of oblique vertical
elastics in combination with a guiding-splint instead of intermaxillary
fixation (IMF).
• Since patients were themselves able to remove splint and elastics at
mealtimes and to clean the appliances from the fifth post-surgical day on,
an early functional adaptation to the altered skeletal and occlusal
relationship was guaranteed, thus avoiding problems involved with
immobilization (Glineburg et al., 1982; Witzmann et al., 1982a,b). As far as
mandibular set-backs were involved, more favourable functional results
compared to those published recently might also be due to the routine
application of an intraoperative method for maintaining condyleposition.
• The method was designed to prevent condyle dislocation due to muscle-
pull, as described by Kundert and Hadjianghelou (1980), and Sund et al.
(1983) and, moreover, to compensate for dislocating forces that might be
exerted if screws were used for fixation of the bony segments.
• In the course of the present study, alterations in mandibular mobility
induced by different treatment methods were detected both incisally and
at the hinge-axis points.
• Both methods showed corresponding results as far as shortand long-
term alterations were concerned, though some deviations in the
intermediate phases were present. Moreover, it was obvious that, if
present at all, deviations were found most often in opening. While
axiographic measurements on opening confirmed the general tendency
found in pro- and laterotrusion, incisal measurements showed a better
recovery in the intermediate phases and a less significant final reduction
in mobility.
• In this respect, it is of importance to consider that the incisal determination
of opening mobility is the only measurement out of a total of 10 different
measurements carried out at any point of time in this study that showed
the result of condyle translation and rotation.
• In contrast, the axiographic measurement of opening mobility revealed
translation of the hinge-axis only. Therefore, deviations between the two
methods as they were found in this investigation seemed to reveal that
long-term reductions in opening were primarily reductions in translatory
capacity. Accordingly, the longer postoperative increase in opening-
capacity measured incisally seemed to be mainly an increase in rotational
capacity.
• Regardless of the exact mechanism, it should be noted that mandibular
mobility in nontreated Class II patients is significantly better than in
healthy Class I adults (Zimmer et al., 1991).
• Therefore, in these patients a loss of protrusive mobility can be seen, at
least in part, as a functional adaptation to Class I values.
• In explaining the loss of mobility after orthognathic surgery, intracapsular
and extracapsular causes have been proposed (Wessberg et al., 1981;
Nitzan and Dolwick, 1989). After LeFort I osteotomies alone and in
combination with a mandibular set-back, only minor reasons such as
transient muscular adaptations and residual areas of inflammation due to
the operative trauma were probable (Tabary et al., 1972; Ingervall et al.,
1979; Wessberg et al., 1981).
• The permanent deficit after mandibular advancements, however, can
reasonably well be explained by insufficient adaptation of the muscles due
to an altered position of skeletal structures (Dechow and Carlson, 1986) or
the intra-articular bony and cartilaginous components (Komposch and
Hockenjos, 1977; McNamara, 1978) due to slight dislocations of the
proximal segment (Freihofer and Petresevic, 1977; Isaacson et al., 1978).
• Furthermore, fibrous disc-fossa adhesions or even a fibrous ankylosis
have been advocated as being responsible for limitations of mandibular
mobility (Nitzan and Dolwick, 1989).
• Although this investigation did not aim to demonstrate the true
mechanism, the finding that the problem of permanent reductions in
mobility could be reduced to the Class II correction and is largely confined
to condylary translatory capacity seems to be of importance.
• Accordingly, functional alterations of the protrusive-acting muscles, as
were demonstrated for the inferior belly of the lateral pterygoid muscle
(Harper et al., 1987), might be important as a causive mechanism.
• Moreover, a displacement and stretching of the antagonistic supra- and
infrahyoid musculature inevitably occurred (Steinhauser, 1973; Poulton
and Ware, 1973; Carlson et al., 1984; Schendel and Epker, 1980). In
studies with monkeys, McNamara (1978) demonstrated a considerable
tendency of lengthened suprahyoid muscles to be restored to their original
positions and function for a limited period.
• Attempts have been made to explain altered TMJ function as a
consequence of orthognathic surgery by biomechanical considerations.
• (Epker and O'Ryan, 1982; Dechow and Carlson, 1986; Kubein-
Meesenburg et al., 1988; KubeinMeesenburg and Nagerl, 1988).
• According to these concepts, alterations in mandibular mobility are a
necessary consequence of the geometric alterations in the craniofacial
relations. With regard to their influence on muscle function, biomechanical
considerations might provide, at least in part, a valuable explanation.